Transcript Urinary Incontinence and Pelvic Organ Prolapse UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series Division of Urogynecology/ Reconstructive Pelvic Surgery.

Urinary Incontinence and
Pelvic Organ Prolapse
UNC School of Medicine
Obstetrics and Gynecology Clerkship
Case Based Seminar Series
Division of Urogynecology/
Reconstructive Pelvic Surgery
Objectives
 Describe normal pelvic anatomy and pelvic support
 Describe screening questions to elicit signs and
symptoms of urinary incontinence
 Differentiate the types of urinary incontinence
 Describe the anatomic changes associated with
urinary incontinence and pelvic organ prolapse
 Describe medical and surgical management options
for urinary incontinence and pelvic organ prolapse
Rationale
 Patients with conditions of pelvic relaxation and
urinary incontinence present in a variety of ways.
 The physician should be familiar with the types of
pelvic relaxation and incontinence and the approach
to management of these patients.
Definition of Urinary Incontinence
 International Continence Society
 Involuntary urine loss
 Severe enough to constitute a social or hygiene problem
 Leakage is objectively demonstrable
Questions for Patients
 Do you leak urine when you cough, sneeze, laugh, or
exercise?
 Do you leak on the way to the bathroom?
 Do you know the locations of bathrooms when you are
shopping or travelling?
 Do you leak during intercourse?
Stress or Urge Incontinence?
Epidemiology
 Estimates of prevalence vary
 Bias in sample surveys
 Patient under-reporting
 Differences in definitions, populations studied and
methods used
 ~ 13 million Americans are incontinent
 10-35% of adults
Economics in Urinary Incontinence
 Direct health care costs
 > $15 billion/yr
 Indirect health care costs
 Incontinence products
 Loss of work/productivity
Classifying Urinary Incontinence
 Stress
 Loss of bladder support -> leak with cough/sneeze/valsalva
 Urge
 Overactive bladder spasms -> leak with urge
 Mixed
 Both of above
 Overflow
 Hyposensitive bladder -> leak when reach capacity
 Other
 Functional – can’t make it to bathroom (physical or
cognitive impairment)
 Unconscious or Reflex – hyperreflexia of detrusor
 Fistula – tract between bladder and vagina
Tenants of Effective Management
 Assessment of patient
 Risk factors and
reversible causes
 Treatment of reversible
conditions
 Education
 Treatment options
 QOL improvement
 Management plan
Risk Factors
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Gender
Immobility
Environmental Barriers
Altered Cognition &
Delirium
 Medications
 Smoking
 Collagen Disorders
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Neurologic Disease
Diabetes
Stroke
Menopause
Childbirth
Increased Abd Pressure
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Obesity
Chronic Constipation
Chronic Cough
High Impact Physical Activity
Patient Evaluation
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History
Physical Exam
Laboratory Tests
Urodynamic Testing
Voiding Diary
History
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HPI
Mental Status Evaluation
Functional Assessment
Environmental Assessment
Social Factors
Voiding Diary
HPI
 # Incontinent episodes
 Triggers
 Stress +/- Urge
 Volume of urine loss
 Difficulty starting stream
(hesitancy)
 Sensation of incomplete
emptying
 Straining to empty
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Number of pads/day
Frequency
Urgency
Nocturia
Enuresis
Dysuria
Hematuria
Post-void dribbling*
*Sign of what?
PMH
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Parity
Birth trauma
Length of labor, especially 2nd stage
Previous gynecologic and/or incontinence
surgery
 Back injury
 Medical History
 MS, DM, CVA, Parkinsons
Medications
 Alpha-adrenergic
 Cholinergic
 Retention
 Bladder irritability
 Alpha-blocking
 Anti-cholinergic
 sphincter tone
 Retention
b
b
b
a
TCA’s are both anticholinergic and alpha adrenergic
Diet
 Caffeine
 Citrus Foods & Drinks
 Cranberry Juice!
 Spicy Foods
 Alcohol
Functional and Environmental Assessment
 Manual Dexterity
 Mobility
 Patient toilet unaided?
 Access
 Distance to toilet or bedside commode (BSC)
 Chair/bed transfers
Voiding Diary
 Date and Time
 Fluid consumption w/ type and volume
 Voiding episodes w/ volume
 Leaking episodes
 Urgency
Physical Examination
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General
GU
Neurologic
Direct Observation of Urine Loss
Post-Void Residual
Q-Tip Test
Physical Examination: Gynecologic
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External Genitalia: excoriation, erythema
Vaginal Introitus and Mucosa: caliber, atrophy
Anterior Vagina: urethral diverticulum
Lateral Vaginal Sidewalls
Posterior Vagina
Uterine or Vaginal Cuff: procidentia, prolapse
Urethra: caruncle
Anus and Rectum: rectal prolapse, sphincter integrity
Physical Examination: Neurologic
 S2 - S4
 Sharp and dull touch
 Perineum and buttocks
 Reflexes
Bulbocavernosus
Anal Wink
Physical Examination: Q-tip Test
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Assesses bladder neck mobility
Sterile technique
Anesthetic gel
+ 30o = UVJ hypermobility
SUI often has hypermobility
Hypermobility not necessarily SUI
- 20o
Urodynamics
 Uroflowmetry
 Cystometrogram
 Leak Testing
 Electromyography
 Micturition Study
 Urethral Pressure
Profile
 Videocystourethrography
 Cystoscopy
Urodynamics
Male or Female?
Laboratory Testing
 Urinalysis and Culture
 Bacterial mucosal irritation
 Unsuppresible detrusor activity
 Endotoxin inhibition of alpha-adrenergic
receptors in urethra
Treatment Options
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Treating Reversible Conditions
Behavioral Therapy
Medications
Devices
Surgical
Reversible Conditions
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UTI
Atrophic urethritis/vaginitis
Stool Impaction
Dietary
Medications
Inadequate/Excess fluid intake
 How many mL/day?
Reversible Conditions
 Delirium
 Psychological
 Restricted Mobility
Treatment: Detrusor Overactivity
 Dietary
 Toileting Habits
 Scheduled Toileting +/- BSC
 Urge Strategies
 Pelvic Muscle Exercises
 Biofeedback
 Electrical Stimulation
Treatment: Detrusor Overactivity
 Bladder has muscarinic receptors (M3)
 Medications
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Ditropan
Detrol
Sanctura
Vesicare
Enablex
Imipramine
Side Effects
 Dry mouth
 Dry eyes
 Constipation
 Cognitive dysfunction
Surgical Treatment: Detrusor Overactivity
 Refractory cases
 InterStim Device
 Percutaneous Tibial Nerve Stim (PTNS)
 Augmentation Cystoplasty
 Many associated complications
 Last resort procedure
Treatment: Stress Incontinence
 Burch Retropubic Urethropexy
 Pubovaginal Sling
 Mesh or Fascial
 Urethral Bulking
 Transurethral injection
Non-Surgical Treatment:
Stress Incontinence
 PESSARY
 Low morbidity
 Requires regular care
 Managed by patient
 Fem-Soft
When to Refer?
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Failed trial of conservative therapy
Pronounced anatomic defect
Persistent infection
Desire or need for surgery
Associated problems
Bottom Line Concepts
 Insert other bottom line concepts here.
 Investigation of the incontinent patient
 History
 Physical Exam
 Urinalysis and Culture
 +/- Urodynamic Testing
 Despite high prevalence and cost, less than 50% of people
with urinary incontinence seek help!
 So ASK your patients about it!
Definition: Prolapse
 ANTERIOR
 Anterior Wall Defect AKA Cystocele
 POSTERIOR
 Posterior Wall Defect AKA Rectocele
 Small Bowel Herniation AKA Enterocele
 LATERAL WALLS
 Paravaginal Defect
 APICAL
 Uterine Prolapse
 Vaginal Vault Prolapse
Etiology
 Childbirth
 Increased Intra-abd
Pressure
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Lifting
Coughing
Obesity
Constipation/Straining
 Neurologic Injury
 Genetic Predisposition
 Connective Tissue
Abnormalities
 Estrogen Deficiency
Normal Pelvic Anatomy
What is
Prolapse?
- loss of support
of vaginal walls
Vesicovaginal
septum
Rectovaginal
septum
Symptoms of Prolapse
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Pressure
Bulging
Vaginal irritation/Ulcers
PAIN IS NOT A PRESENTING SYMPTOM
Compartment-Specific Prolapse Symptoms
 ANTERIOR
 Stress urinary incontinence
 Incomplete bladder emptying
 Possible increased frequency of UTIs
 POSTERIOR
 Incomplete stool evacuation
 Splinting to assist defecation
Consequence of Prolapse
Prolapse Diagnosis: Pop Q
Prolapse Therapy
 Conservative Therapy
 Pelvic Floor Muscle Exercises
 Pessary
 Surgical Therapy
 Based on location of prolapse
 Anterior, Posterior, Apical, Uterine
Pelvic Organ Prolapse Repair
 Anterior
Compartment
 Weakness of
vesicovaginal septum
Pelvic Organ Prolapse Repair
 Anterior
Colporrhaphy
 Reinforcement and
repair of vesico-vaginal
supportive tissue
 Non-permanent
plication sutures
Pelvic Organ Prolapse Repair
 Posterior
Compartment
 Weakness of
rectovaginal septum
 Denonvillier’s “fascia”
Pelvic Organ Prolapse Repair
 Posterior
Colporrhaphy
 Reinforcement
and repair of
rectovaginal
septum
 Non-permanent
plication
sutures
Pelvic Organ Prolapse Repair
 Lateral
Compartments
 Detachment of lateral
walls of vagina from
Arcus Tendinius Fascia
Pelvis
 “White line”
Pelvic Organ Prolapse Repair
 Lateral Compartments
 Reattachment of vaginal supportive tissue to white
line
Pelvic Organ Prolapse Repair
 Apical
Compartment
 Uterosacral ligaments
to …
 Uterus/cervix
 Vaginal cuff
Cervical Os
Pelvic Organ Prolapse Repair
 Apical
Compartment
 Attachment of
uterosacral
ligaments to
vaginal cuff
Pelvic Organ Prolapse Repair
 Apical
Compartment
 Attachment of
vaginal cuff to
anterior longitudinal
sacral ligament
using a graft
Sacrum
Vagina
Robotic Sacrocolpopexy
 Apical Compartment
 Robotically-Assisted
Laparoscopy
 da Vinci® surgical system
 Approved in 2005
 Hysterectomy
 Myomectomy
 Sacrocolpopexy
Questions?
Bottom Line Concepts
 Many types of Urinary Incontinence
 Stress
 Urge
 Mixed
 Overflow
 Other
 Functional
 Unconscious or Reflex
 Fistula
 Treatments include
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Diet
Medication
Biofeedback
Pessary
Surgery
Bottom Line Concepts
 Prolapse is associated with pressure, but not pain
 Site-specific exam
 Assess each compartment – anterior, posterior, apical, uterine
 Use Q-tip and speculum to identify specific prolapse
 Site-specific approach to repair
 Anterior, posterior, apical, uterine
 Treatment focused on symptom improvement, not anatomical
correction
References and Resources
 APGO Medical Student Educational Objectives, 9th edition, (2009),
Educational Topic 37 (p78-79).
 Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010),
Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William
NP Herbert, Douglas W Laube, Roger P Smith. Chapter 28 (p259-268).
 Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and
Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone,
Calvin J Hobel. Chapter 23 (p276-289).